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RESEARCH/Original Article
Implementation factors are neglected in
research investigating telehealth delivery
of allied health services to rural children:
A scoping review
Jessica Campbell
1,2
, Deborah Theodoros
1,2
,
Nicole Hartley
2,3
, Trevor Russell
1,2
and Nicole Gillespie
2,3
Abstract
Introduction: Rural children are likely to benefit from the telehealth delivery of multidisciplinary allied healthcare.
This study aimed to (a) identify the scope of literature describing the telehealth delivery of allied health services to
children living in rural areas and (b) understand the extent to which implementation – that is, specific activities designed
to put telehealth into practice – has been investigated in such literature.
Methods: Systematic scoping review methodology was used to locate studies in which telehealth delivered allied health
services to children aged 0–12 who lived rurally (January 1998–January 2018). Two reviewers screened the studies,
extracted data and appraised quality with Critical Skills Appraisal Programme checklists. Databases searched were
PubMed, MEDLINE, CINAHL, PsycINFO, ERIC and Cochrane Library.
Results: Data were extracted from 23 papers (two randomised controlled trials, one pseudorandomised controlled
trial, one non-randomised experimental trial, two interrupted time series without parallel control groups, 10 case series
and seven studies of diagnostic yield). Most were level III (n¼4) or IV (n¼17) when classified according to National
Health and Medical Research Council guidelines. One study met all Critical Skills Appraisal Programme quality criteria.
Allied healthcare interventions were aimed at improving functioning in communication (n¼10), behaviour and socio-
emotional domains (n¼8) and identifying hearing concerns (n¼5). Many studies (n¼12) identified implementation
facilitators, largely training and equipment. Only one study referred to an explicit framework for telehealth implemen-
tation (user-centred design).
Discussion: Future research should target occupational therapy, physiotherapy, dietetics and social work, and deter-
mine the implementation factors and models likely to create successful telehealth services for this population.
Keywords
Allied health, telehealth, therapy, children, rural, implementation
Date received: 9 April 2019; Date accepted: 21 May 2019
Introduction
Many countries contend with gaps between rural and
urban child health.
1,2
In Australia, the proportion of
children developmentally vulnerable on all five
domains of the 2018 Australian Early Development
Census increased with distance from major cities.
In the physical health and well-being domain, 8.7%
of children in major cities were developmentally vulner-
able, compared with 10.9% in inner-regional areas,
12.1% in outer-regional areas, 13.8% in remote areas
and 23.3% in very remote areas.
3
Children were
1
School of Health and Rehabilitation Sciences, The University of
Queensland, Australia
2
Centre of Research Excellence in Telehealth, Faculty of Medicine, The
University of Queensland, Australia
3
UQ Business School, The University of Queensland, Australia
Corresponding author:
Jessica Campbell, School of Health and Rehabilitation Sciences, Level 3,
Therapies Annexe (84A), The University of Queensland, St Lucia QLD
4072, Australia.
Email: jessica.campbell@uq.net.au
Journal of Telemedicine and Telecare
0(0) 1–17
!The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1357633X19856472
journals.sagepub.com/home/jtt
similarly more vulnerable as remoteness increased on
the social competence, emotional maturity, language
and cognitive skills (school-based), and communication
skills and general knowledge domains.
3
Allied health professionals are trained in the manage-
ment of developmental physical, social, cognitive and
communication issues. In Australia, fewer of these pro-
fessionals are available in remote areas.
4
For instance, in
2012 there were 68.2 occupational therapists per 100,000
population in major cities, 48.3 in inner regional areas,
48.4 in outer regional and 23.1 in remote/very remote
areas.
5
Rural children and their families often need to
travel considerable distances for therapy.
6
Telehealth
(TH) may mitigate such barriers. For example, a child
with language and cognitive concerns living in a town
without an allied health service could receive consulta-
tions at home with a speech-language pathologist and
psychologist in a metropolitan area via videoconferenc-
ing. However, TH adoption is slow and patchy
7
and
faces additional challenges in rural Australia where
internet penetration and broadband connectivity lag
behind metropolitan areas
8
and where there may be
low community awareness of TH.
9
In light of these bar-
riers, research is needed that not only investigates TH
allied healthcare to rural areas but also explores activi-
ties to bring such services into practice (implementation).
The aim of this review was to (a) identify the scope
of literature describing TH delivery of allied health
services to rural children and (b) identify the extent
to which the implementation of such services has
been investigated.
Methods
A systematic scoping review was conducted for this
study. The first author (JC) developed a scoping
review protocol based on published guidelines,
10,11
including eligibility criteria, search terms and strategies,
quality appraisal criteria and extraction methods. The
protocol was reviewed by all other authors for adher-
ence to scoping review methodology.
PubMed, Medline and CINAHL via EBSCOHost,
PsycINFO, Education Resources Information Center
(ERIC) and Cochrane Library electronic databases
were searched. Grey literature was identified by search-
ing Google, Google Scholar and websites of organisa-
tions known to provide rural paediatric allied health.
The inclusion and exclusion criteria for this study
are provided in Table 1. Study participants of interest
were aged between 0 and 12 years. Interventions that
were delivered in areas described as rural, regional,
remote, a small town, village or hamlet were included.
Any intervention provided by a clinician commonly
employed in multidisciplinary therapeutic practices
with a developmental focus was of interest (occupa-
tional therapist, physiotherapist, speech-language
pathologist, psychologist, social worker, mental
health worker, audiologist, dietician), including if
these personnel worked in teams with non-allied
health clinicians. Interventions that did not require an
allied health clinician, such as an entirely self-directed
Internet therapy portal, were not included. At least one
outcome that measured child functioning was required.
All TH modalities, such as telephone, videoconference,
email, web-based and mobile applications, were includ-
ed. The last 20 years of literature were included given
the increase in TH literature since 2000
12
and the rapid-
ity of technology development. Research protocols,
proposals, abstracts, posters, editorials, and opinion
and background articles were excluded as a lack of
detailed findings prohibited data extraction. The last
search date was 17 September 2018.
Table 1. Inclusion and exclusion criteria.
Inclusion criteria Exclusion criteria
Participant Children aged 0–12 years Age not described
Number of children not described
Intervention Service accessed from rural, regional or remote area, small town,
village or hamlet or a combination of rural and urban areas
Care provided by occupational therapist, physiotherapist, speech-
language pathologist, psychologist, social worker, mental health
worker, audiologist, dietician or a combination of these with
other personnel
Care provided at a distance or combination of in-person and
distance via a telecommunications technology (e.g. telephone,
videoconference, email, web/mobile application)
Location not described
Number of rural participants not described
All care non-allied health (e.g. medicine,
psychiatry, pathology, dentistry,
radiology, pharmacology)
Professional-to-professional interventions
(e.g. professional development)
Outcome At least one child functioning outcome
Study design English language
Published 1 January 1998–17 September 2018
Research protocol/proposal
Abstract/poster presentation
Opinion/editorial/background article
2Journal of Telemedicine and Telecare 0(0)
The search terms for four key concepts (child,tele-
health,allied health and rural) were developed by JC
and discussed with a health science librarian and the
other authors (see supplementary material).
The references of included articles were manually
checked for further articles. Search results were
imported into Rayyan QCRI software (Qatar
Computing Research Institute, Doha, Qatar) for dupli-
cate removal and blinded eligibility assessment. JC and
a research assistant (RS) screened manuscripts by
abstract and then full text against the aforementioned
criteria. Disagreements were discussed until a consen-
sus was reached.
A spreadsheet prepared by JC and reviewed by the
remaining authors was used to extract data from the
included studies. In a similar procedure to Tricco
et al.,
10
JC extracted data, RS verified the extracted
data and two other authors (DT, NH) checked any
major changes (those that required a change in
National Health and Medical Research Council
(NHMRC) level).
To address the first research objective, items for
extraction were: study type and level of evidence
using NHMRC terminology,
13
discipline, participants,
intervention, comparison, outcomes and findings.
Critical Skills Appraisal Programme (CASP) check-
lists
14
were completed to appraise the quality of studies,
including risk of bias and confounding factors. An
adapted quantitative research checklist
15
was used in
place of the case-control checklist to ensure questions
were relevant to a broad range of study types (Table 2).
To address the second research objective, items
extracted included description of the TH service
model, location of service provision, measures taken
by the authors or recommendations made to facilitate
TH implementation and model of implementa-
tion used.
Results
Scope of literature
The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) flow diagram summa-
rises the search results
16
(Figure 1).
The data extracted are presented in Tables 3 and 4.
Of the 23 articles selected for data extraction, all
were NHMRC evidence level II or below: two level II
randomised controlled trials
17,18
; one level III-1 pseu-
dorandomised controlled trial
19
; one level III-2
non-randomised experimental trial
20
; two level III-3
interrupted time series without parallel control
groups
21,22
; 10 level IV case series
23–32
; and seven
level IV studies of diagnostic yield.
33–39
Although
grey literature was searched, all results were excluded
as they lacked child functioning measures.
Participants. Most studies were conducted solely with
rural participants, except two that described a combi-
nation of rural and urban.
31,32
Eleven studies took
place in the USA,
19–23,26,28,29,31,34,35
six in
Australia,
17,18,24,25,32,39
three in Canada
27,30,33
and
three in India.
36–38
Participants included infants under 24 months,
26,34
preschool children from 24 months to six
years,
17,23,26,32,37,38
school-aged children over six and
under 12 years,
20,21,27,35,39
both preschool and school-
aged children
18,19,22,24,25,28,29,33,36
and both school-aged
Table 2. Adapted questions substituted for CASP case-control checklist.
Original question Adapted question
1. Did the study address a clearly focused issue? –
2. Did the authors use an appropriate method to answer
their question?
–
3. Were the cases recruited in an acceptable way? –
4. Were the controls selected in an acceptable way? –
5. Was the exposure accurately measured to minimise bias? –
6. Aside from the experimental intervention, were the groups
treated equally?
Was the outcome accurately measured
to minimise bias?
7. Have the authors taken account of the potential confounding
factors in the design and/or in their analysis?
–
8. How large was the treatment effect? Was the follow-up of subjects complete enough?
Was the follow-up of subjects long enough?
9. How precise was the estimate of the treatment effect? Have ethical issues been taken into consideration?
10. Do you believe the results? –
11. Can the results be applied to the local population? –
12. Do the results of this study fit with other available evidence? –
–¼original question used.
Campbell et al. 3
children and adolescents.
30,31
Two studies reported the
inclusion of indigenous children.
25,33
Interventions. A wide variety of allied health disciplines
were identified. Ten studies targeted communication
and were conducted by speech-language
pathologists.
19,20,22,25,27,29,30,32,33,39
Participants were
children with fluency disorders,
30,32
speech-sound dis-
orders,
20,22
speech and language concerns,
27,33
commu-
nication concerns,
25
reading and language concerns
39
and the caseload of a school-based therapist.
19
Seven
studies targeted behaviour or socio-emotional skills,
including: psychologists working with children with
behavioural concerns
17,21,28
; behaviour analysts work-
ing with children with autism
23
; a psychologist and
social worker providing cognitive behavioural therapy
for children with post-traumatic stress disorder
31
; and
parent support practitioners supervised by mental
health clinicians working with children with disruptive
behaviour, attention-deficit hyperactivity and learning
difficulties
18
or unknown presentations.
24
Six studies
involved audiologists screening or assessing general
paediatric populations.
26,34–38
No occupational thera-
py, physiotherapy, dietetic or social work studies
were identified.
TH intervention types also varied. Twelve studies
dealt with therapy only.
17–20,22,24,25,28–31,37
Eight stud-
ies dealt with assessment only.
23,26,33,35–39
Three studies
involved both assessment and therapy.
21,23,27
Of the 15
studies that included some type of therapy, seven used
traditional clinician-directed, child-focused
therapy.
19,20,22,25,27,29,31
Other therapy models includ-
ed: parents implementing strategies supported by writ-
ten materials and telephone support
17,18,24
; parents
implementing therapy with in-depth structured training
and support
28,32
; and teachers implementing interven-
tions with clinician observations, feedback and data
collection.
21
Service delivery models. Most studies involved TH with-
out an in-person component.
17–24,26,28–32
Hybrid TH-
in-person models included in-person assessment before
TH therapy
25,27
and comparing TH and in-person
methods of assessment.
33–39
Different tiers of service provision were also
described. Three studies looked at universal care pro-
vision. These were hearing screenings provided to a
large number of villages in India
37,38
and a parenting
intervention available to all parents who wished to
access the service in an Australian state (Victoria).
24
Seven studies were targeted at particular groups of
participants. These were designed to reduce behaviou-
ral problems,
17,18,28
identify hearing concerns in class-
rooms
35,36
or a village,
34
or assess infants who had
failed newborn hearing screening.
26
Twelve studies investigated specialised support for
individual participants.
20–23,25,27,29–33,39
Personnel who conducted studies varied. Most stud-
ies (n¼17) involved the use of an assistant, parent or
second clinician at the client’s end to usher clients
into sessions, help children participate in activities
and manipulate technology.
19–23,25–27,29,30,33–36,38,39
The remainder were conducted by clinicians alone,
with the parent receiving the service
17,18,24,28,32
or
school-aged children receiving cognitive behavioural
therapy without assistance.
31
Modalities. TH modalities were dominated by
videoconferencing.
19,21,23,25,27–31,33,39
Two speech-
language pathology studies used enhanced videoconfer-
encing with inbuilt rewards and activities.
20,22
Audiological studies combined remote computing
with videoconferencing,
26,34,37,38
with some adding
store-and-forward emailing of video files.
35,36
Telephone was used for parent support.
17,18,24,32
Sites. In 11 studies, participants received services in
schools, preschool, early childcare centres or a combi-
nation of schools and other locations.
19–
21,23,25,27–29,31,35,36,39
Participants also received services
at home,
17,18,22,24,32
in community settings,
27,33,37,38
in
medical centres
30,34
or at a university.
26
More than half
of the studies described clinicians providing services
Records identified through
database searching
(n=453)
Additional records
identified through other
sources (n=13)
Records before duplicates
removed
(n=466)
Duplicates removed
(n=162)
Records screened by title
and abstract
(n=304)
Records excluded
(n=207)
Full text articles assessed
for eligibility
(n=97)
Records excluded (n=74)
No child functioning outcomes (n=16)
Location not described (n=14)
Opinion/editorial/background article
(n=9)
No rural participants (n=8)
Average age of participants > 12 years
(n=9)
Intervention not allied health (n=5)
Research protocol/proposal (n=4)
Number of child participants not
described (n=4)
Number of rural participants not
described (n=3)
Professional-to-professional interventions
(n=1)
Abstract/poster presentation (n=1)
Articles included in data
extraction
(n=23)
Figure 1. PRISMA flow diagram for the study’s search process.
4Journal of Telemedicine and Telecare 0(0)
Table 3. Discipline, participants, intervention, comparison, outcomes and findings extracted data and NHMRC level achieved and CASP criteria filled.
Study
NHMRC
level Discipline Participants (Ix group) TH Ix Comparison Outcomes Findings
CASP
criteria
Barretto
et al. (2006)
23
IV Behaviour analysis 5-year-old boy and 1-year-
old girl with severe
problem behaviour
Brief functional behav-
iour analysis
Nil Disruptive behaviour
target
responses frequency
Brief functional behaviour
analyses are feasible via TH
7/10 (70%)
Bice-Urbach
et al. (2016)
21
III-3 Psychology 6 Caucasian female
teachers, 6 Caucasian
boys, mean age 7.5
years (range 5–10)
with disrup-
tive behaviours
Trained psychology graduate
student provided problem-
solving consultation to
teacher via 5 structured
VC interviews
(15–90 min). Teachers
implemented
recommendations
Within-subject multi-
ple baseline
Child observation data,
goal attainment, treat-
ment fidelity, percep-
tions of feasibility,
acceptability,
effectiveness
Decrease in disruptive
behaviour, increase in goal
attainment, teacher adher-
ence ranged from low to
high, moderate to high
perception of feasibility,
acceptability, effectiveness
4/12 (33%)
Cann et al. (2003)
24
IV Parent-support prac-
titioner supervised
by psychologist
73 families with low
socio-economic status:
children with mean age
5 (SD 2.5, range 1–11)
with disrup-
tive behaviour
10 weeks of weekly tele-
phone calls (15–30 min)
with self-help book
and video
Nil Child behaviour, parenting
styles, parenting com-
petence, parenting
depression, parenting
problems, dyadic
adjustment, satisfaction
Decrease in problem behav-
iour and dysfunctional
parenting styles, increase
in competence, decrease
in depression and parent-
ing problems, no change in
adjustment, very high
satisfaction
6/11 (55%)
Eriks-Brophy
et al. (2008)
33
IV Speech-language
pathology
7 children (age range 4
years 3 months–12
years 9 months)
One-off speech and language
Ax performed by remote-
site SLP via VC
Simultaneous Ax by
on-site SLP
Percentage agreement on
subtests, number and
type of disagreements
High agreement for receptive
language and vocabulary
abilities lower for
articulation
2/12 (17%)
Fairweather
et al. (2016)
25
IV Speech-language
pathology
1. 19 children, mean age
7.8 (range 3–12) with
communication skill
difficulty
2. 5 parents (four women,
1man)
IP Ax (2 hours) then 3–6
fortnightly remote ses-
sions (mean 4.9) 30 min
over 12 weeks
Within-subject
pre-post
Goal attainment, inter-
views with parents
Some progress on most goals,
parents saw Rx as feasible
5/12 (42%)
Grogan-Johnson
et al. (2010)
19
III-1 Speech-language
pathology
Between 32 and 36 chil-
dren (age range 4–12
years) with articula-
tion, language and/or
fluency disorders
22 parents, 4 local SLPs, 4
e-helpers, 4 principals
WL control: Group A
(n¼17) and Group B
(n¼17)
4 months of individual TH Rx
following goals and objec-
tives on each child’s IEP
with e-helper present
4 months of conven-
tional IP Rx pri-
marily in groups of
2–4 students
Student progress, parent
and teacher satisfac-
tion, log for call quality
and cancellation
Most students made adequate
progress, high satisfaction,
similar cancellation rate to
general school rate
5/12 (42%)
Grogan-Johnson
et al. (2011)
20
III-2 Speech-language
pathology
7 children mean age 9.56
(range 7 years 1
month–11 years 11
months), 6 male, 1
female, with articula-
tion impairment
20–40 min individual Rx,
24–48 sessions
6 children, mean age
8.36 (range 6 years
3 months–10 years
9 months), 5 male,
1 female, with
articulation impair-
ment
Articulation test scores,
Rx targets % correct,
progress
report indicators
No difference in scores,
improvement in most tar-
gets, positive change on
most progress indicators
6/12 (50%)
(continued)
Table 3. Continued
Study
NHMRC
level Discipline Participants (Ix group) TH Ix Comparison Outcomes Findings
CASP
criteria
Rx 20 min of individual
Rx, 21–28 sessions
Hayes et al. (2012)
26
IV Audiology 9 infants aged 2–3 months Hearing screening: tympan-
ometry, ABR, frequency-
specific auditory steady-
state response
(ASSR), DPOAE
Nil Screening results 3 infants ¼typical hearing;
2¼mild hearing loss (HL)
and middle-ear dysfunc-
tion; 4 ¼unilateral con-
ductive HL; 1 ¼unilateral
sensorineural HL;
1¼unilateral audito-
ry neuropathy
4/11 (36%)
Jessiman (2003)
27
IV Speech-language
pathology
7-year-old and 5-year-4-
month-old with articu-
lation and lan-
guage concerns
TH administration of, articu-
lation test, TH speech and
language Rx 30–60 min,
twice a week for
four months
IP articulation test Articulation test score,
language test score,
satisfaction
Results described but data
not presented
TH Rx appears feasible
4/11 (36%)
Krumm et al. (2008)
34
IV Audiology 30 full-term infants aged
11–45 days (mean 16 d;
SD 8 d), 18 males, 12
females, did not pass
DPOAE screening
at birth
One-off DPOAE and ABR
screening via
remote computing
IP audiologist Screening results agree-
ment, variance
within trials
Identical screening results in
both conditions, no signifi-
cant difference in
variability
9/12 (75%)
Lancaster
et al. (2008)
35
IV Audiology 32 children (age range 8–
9 years), 17 boys,
15 girls
One-off hearing screening:
1. Video-otoscopy screening
interpreted real-time by
remote audiologist via VC
2. Tympanometry immittance
(middle-ear functioning)
results emailed to remote
audiologist for interpreta-
tion
3. PTA screening conducted
in real time via remote
computing and VC
IP audiologist Screening results agree-
ment, sensitivity and
specificity of
TH screens
Identical screening results for
otoscopy and immittance,
PTA results differed for
five students. High sensi-
tivity and specificity for TH
otoscopy and immittance
procedures. High sensitivi-
ty, low specificity for TH
PTA screening
10/10 (100%)
Lee (2018)
22
III-3 Speech-lan-
guage pathology
3 children (1 dropout due
to Internet difficulties)
Child A: 4-year-10-
month-old boy Child B:
6-year-old boy with
phonological disorders
30-min multiple opposition
phonological Ix twice a
week. Child A: 24 Rx ses-
sions (12 weeks). Child B:
32 Rx sessions (16 weeks)
Within-subject multi-
ple baselines
Rx target probes articu-
lation test score
Increased accuracy in targets,
improvement in
test scores
9/12 (75%)
Markie-Dadds and
Sanders (2006)
17
II Psychology 41 families (child mean
age 47.21 months, SD
10.19, range 2–6
years), mother’s mean
age 37.38 years (SD
4.33), father’s mean age
Enhanced Self-Directed (ESD)
program (n¼14) using
written materials and
weekly telephone consul-
tation with psychologist
(mean 20 min, range 5–30)
over 12 weeks
1. Self-help (SD) pro-
gram (Every Parent)
using written
materials (n¼15)
2. WL (n¼12)
Child behaviour, parenting
styles, parenting com-
petency, parenting
problems, depression,
satisfaction
ESD showed lower levels of
child problem behaviour
than SD and WL, increas-
ing mother’s parenting
styles and competency, no
effect on depression or
8/11 (72%)
(continued)
Table 3. Continued
Study
NHMRC
level Discipline Participants (Ix group) TH Ix Comparison Outcomes Findings
CASP
criteria
37.38 (SD 6.92), 31
boys, 10 girls
parenting problems, higher
satisfaction in ESD than SD
Monica et al. (2017)
36
IV Audiology 31 children (5–8 years)
enrolled in grade 1
One-off hearing screening
(video-otoscopy video
emailed to examiner), real-
time PTA, DPOAE by
remote control and VC
IP audiologist Screening results agree-
ment, DPOAE signal to
noise ratio, test-
ing time
Comparable results
between methods
9/10 (90%)
Ramkumar
et al. (2018)
37
IV Audiology 119 children under 5 ABR testing via remote com-
puting and VC
IP village health
worker
DPOAE screening
Sensitivity and specificity,
positive predic-
tive values
Acceptable sensitivity and
predictive values
7/10 (70%)
Ramkumar
et al. (2018)
38
IV Audiology 19 children under 5 ABR testing in mobile tele-
van via satellite or at local
centre via broadband
IP village health
worker
DPOAE screening
Cost per child screened,
followed up, confirmed
with hearing loss,
sensitivity
Costs greater using tele-van 3/12 (25%)
Reese et al. (2015)
28
IV Psychology 1. 13 (3 dropouts)
parents/guardians,
mean age 39.1 years
(range 21–64)
2. 11 children, mean age
7.6 (range 5–11),
8 male, 3 female, with
ADHD or attention/
concentration
problems
Group parenting program via
VC, 8 weekly sessions
Within-subject
pre-post
Child behaviour, parenting
styles, parenting prob-
lems, relationship qual-
ity, parent depression,
satisfaction
Improved behaviour and par-
enting outcomes, positive
satisfaction
8/11 (73%)
Scheideman-Miller
et al. (2002)
29
IV Speech-language
pathology
Pre-pilot: 6 children (age
range 3–9), 3 boys, 3
girls, mild to moderate
articulation deficits,
unknown number of
therapists and teachers
Pilot: 11 students, 2nd
grade or older with
language or articula-
tion deficits
Pre-pilot: 5 weeks of speech-
language pathology Rx
Pilot: individual Rx for 30
minutes 2/week for 30
weeks, across two years
Pre-pilot: 1 boy, 2
girls, aged 4–10
Pilot: nil
Pre-pilot: functional out-
comes measures, satis-
faction
Pilot: Rx time lost due to
technical difficulties
Pre-Pilot: improved function-
ing, high satisfaction
Pilot: TH can be used effec-
tively for articulation and
language interventions
1/12 (8%)
Sicotte et al. (2003)
30
IV Speech-language
pathology
6 participants, 4 children
(aged 4, 5, 7 and 12),
two adolescents (aged
17 and 19)
Stuttering Rx: 12 individual,
1-hour weekly sessions (2
children) or 20 individual,
1-hour weekly sessions
(4 children)
Nil Attendance, clinician and
child or parent client
satisfaction, percentage
syllables stuttered
100% attendance, moderate–
high satisfaction,
reduced stuttering
4/11 (36%)
Stewart et al. (2017)
31
IV Psychology and
social work
15 youths, mean age
10.80 (range 7–16),
93.3% female, with
Trauma-focused Cognitive
Behavioural Therapy (TF-
CBT) 12–20 weekly
Within subjects
pre-post
Strategies for TH, equip-
ment performance,
safety issues, sessions
Use of Adobe pdf/Word,
occasional equipment
problems, no safety
8/12 (67%)
(continued)
Table 3. Continued
Study
NHMRC
level Discipline Participants (Ix group) TH Ix Comparison Outcomes Findings
CASP
criteria
post-traumatic stress
disorder or adjust-
ment disorder
sessions provided by
English and Spanish bilin-
gual psychologist and
social worker
attended, treatment
completion, clinical
outcomes, caregiver
satisfaction
problems, Mean 14.13
sessions attended, no
dropouts, decreased PTSD
symptoms and problem
behaviour, high satisfaction
Sutherland
et al. (2017)
39
IV Speech-language
pathology
23 children mean age 9
years 11 months
(range 8–12 years), 18
male, 5 female, with a
history of reading diffi-
culties and known/sus-
pected language
impairment attending
mainstream schools
referred to specialist
reading centre
One-off language Ax Clinical
Evaluation of Language
Fundamentals 4th Edition
(CELF-4) (4 of 6 subtests)
IP SLP simultaneously
rated
same subtests
Sessions completed,
audio/video quality,
reliability and agree-
ment on test, child
behaviour, parent
satisfaction
All sessions completed, most
sessions good audio/video,
strong inter-rater reliabili-
ty, good agreement, similar
behaviour, satisfaction
largely positive
7/12 (58%)
Swift et al. (2009)
18
II Parent-support prac-
titioner supervised
by mental health
specialist
29 children, mean age 7
(range 2–12), 25 boys,
4 girls, referred for
disruptive behaviour,
attention-deficit hyper-
activity and learning
difficulties
Parenting program self-help
book workbook and
resources, weekly or fort-
nightly calls with practi-
tioner, approx. 2 hours
over 12 weeks
Within-subjects wait-
ing list control
Child behaviour, parent
satisfaction
Improved behaviour, high
satisfaction
6/11 (55%)
Wilson et al. (2004)
32
IV Speech-language
pathology
5 children with early
stuttering, aged 3 years
8 months–5 years 7
months, 3 girls, 2 boys
Lidcombe program of Early
Stuttering Intervention and
video training materials. 3–
34 consultations per client
Nil Syllables stuttered, sylla-
bles per minute, Rx
efficiency, parent
satisfaction
Stuttering reduced, higher
syllables per minute, effi-
ciency close to standard
delivery, most
parents satisfied
10/12 (83%)
SD: standard deviation; Ax: assessment; ABR: auditory brainstem response; DPOAE: distortion product otoacoustic emissions Dx: diagnosed; IP: in-person; Ix: intervention; PTA: pure tone audiometry; Rx: therapy; SLP:
speech-language pathologist; TH: telehealth; VC: videoconference.
Table 4. TH service model, locations, implementation actions/recommendations/model extracted data.
Study Service model A: Locations B: Patient provider Implementation actions Implementation recommendations
Implementation
model
Barretto et al.
(2006)
23
Remote consultant collected infor-
mation about children, conducted
brief VC Ax. Assistants were:
Child A: teacher and school psy-
chologist. Child B: foster mother
and physical therapist at local
Department of Human
Service Office
A: Local schools and local
Department of Human
Services office, Iowa, US
B: Telemedicine studio, Center
for Disabilities and
Development at University of
Iowa Hospitals and Clinics
Nil Nil Nil
Bice-Urbach
et al. (2016)
21
Consultants observed child, met with
teacher via VC to the classroom.
Teacher implemented Ix in class
A: Classroom of two public
schools without full-time
school psychologist in rural
Midwestern US towns (pop-
ulation <5000)
B: University office
Psychologist provided teacher tuto-
rial on technology equipment and
helped set up equipment
Nil Nil
Cann et al.
(2003)
24
Trained professional made phone
contact as parents completed self-
help program
A: Parent’s home (rural Victoria)
B: Not described
Nil Nil Nil
Eriks-Brophy
et al. (2008)
33
On-site SLP engaged child in conver-
sation and facilitated testing.
Remote SLP conducted testing
via VC
A: Small remote Ontario
Aboriginal Community,
Canada
B: Not described
Children given basic introduction to
technology before beginning Ax
Off-site SLP to develop cross-cultural sensi-
tivity, be familiar with technology, poten-
tial bias, administration and scoring
difficulties. Assistant to serve as cultural
informant. SLP and assistant to establish
relationship and develop reliability in
scoring prior to Ax. Access a local person
with some knowledge of technology.
Create protocol to alert participants if
system disconnects. Use wireless micro-
phone for child and good quality head-
phones for SLP
Nil
Fairweather
et al. (2016)
25
IP Ax, TH Rx via VC, IP reviews. Rx
assistant practiced Rx
between sessions
A: 15 children at six school sites,
four children at early childcare
sites, rural New South Wales,
Australia
B: Royal Far West, Sydney
Nil Meet with parents/caregivers IP prior to
improve engagement. Eliminate barriers
for employing Rx facilitators. Improve and
monitor connectivity, audio output and
communication between stakeholders
Nil
Grogan-Johnson
et al. (2010)
19
Ax conducted prior. SLP provided
VC PC-based Rx with headphones
via educational network
at minimum bandwidth of
10 Mbits/s
E-helper escorted children to and
from sessions, solved technology
problems, provided adult supervi-
sion, received and sent faxes and
A: Four rural Ohio elementary
schools, US
B: Not described
E-helpers trained: TH equipment,
basic troubleshooting strategies,
responsibilities, maintenance of
confidentiality
Nil Nil
(continued)
Campbell et al. 9
Table 4. Continued
Study Service model A: Locations B: Patient provider Implementation actions Implementation recommendations
Implementation
model
mail for SLP, sent home
paperwork
Grogan-Johnson
et al. (2011)
20
SLP provided Rx from university to
school via enhanced VC (TinyEYE
Speech Therapy Software) with
assistance of e-helper (set up
technology, fetch child)
A: Rural Ohio elementary
schools, US
B: Kent State University
E-helpers trained (1 hour): TH
equipment, basic troubleshooting
strategies, responsibilities, main-
tenance of confidentiality
Pullout model of Rx makes it hard to col-
laborate with classroom teachers and
relate intervention to current classroom
curriculum. Challenges can be minimised
by collaborating via email, scheduled VC
meetings with teachers and using e-help-
ers to gather information
Nil
Hayes et al.
(2012)
26
Audiologist conducted hearing
screening via VC with remote
control of diagnostic equipment
assisted by audiometrists
A: Guam Early Hearing Detection
and Intervention (EHDI)
B: Children’s Hospital Colorado
1. Memorandum of understanding
regarding roles
2. US audiologists obtain Guam
licenses
3. Training of audiometrists by
audiologists
4. Week-long site visit by audiologists
(meet stakeholders, evaluate site,
set-up and test equipment, train
audiometrists, develop
joint procedures)
1. Local licensure must be obtained
2. Address image, sound quality and data
transmission rate by using two computers
at each site
3. Obtain informed consent including specific
language
4. Use secure software and limit patient-
identifying information
5. Maintain clinical standards by using of
same diagnostic protocol as IP services
6. Select appropriate patients (i.e. infants
who reasonably can be tested in natural
sleep)
7. Develop a 5-min video about the proce-
dure for parents
8. Clinician and administrative support for
telepractice is important
9. Test/retest internet connectivity during
periods of peak Internet traffic. Establish
backup communication options
10. Deliver such screening integrated within
an Early Hearing Detection and
Intervention context
Nil
Jessiman
(2003)
27
SLP provided tele-therapy to parents
and child via VC. Minimally trained
TH facilitator (clinic receptionist)
shown how to use the equipment
and instructed parents in its use
A: Community health clinic
room, Alberta, Canada
B: Keeweetinkok Lakes Regional
Health Authority, Slave
Lake, Alberta
Therapist met with parents and
teachers at child’s school to
explain program prior to
commencement
1. Equipment should be good quality to
improve identification of articulation
errors (head-mounted microphones, split
screen)
2. Room set-up should be optimal (acoustic
and visual treatment, comfortable furni-
ture)
3. Trained facilitators should be available at
both sites
4. Select clients carefully (motivated families,
children who can focus, attend and sit for
Nil
(continued)
10 Journal of Telemedicine and Telecare 0(0)
Table 4. Continued
Study Service model A: Locations B: Patient provider Implementation actions Implementation recommendations
Implementation
model
sessions). Shorter sessions for young
children
5. Direct Rx with children recommended
before work focused on parents/assis-
tants
6. Client sites need access to Rx materials
for parents/assistants
Krumm et al.
(2008)
34
Remote audiologist used remote
computing to control DPOAE and
ABR equipment remotely. On-site
audiologist instructed parents,
inserted DPOAE probe, applied
AABR electrodes and
fitted earphones
A: Utah Valley Regional Medical
Center, US
B: Utah State University,
200 km away
Onsite audiology set-up Consider future studies with screening
assistants and what training screening
assistants need for setup at remote sites
Nil
Lancaster et al.
(2008)
35
On-site trained assistant performed a
variety of tasks, including video-
otoscopy and headphone place-
ment, emailing results to off-site
audiologist
A: Fielding Elementary School
library, Utah, US
B: Utah State University in Logan,
30 miles away
Nil Trained facilitators are necessary. Initial set-
up costs and periodic maintenance
required. School bandwidth may be limit-
ed but did not affect this study. Arranging
direct network access requires consider-
able coordination. Audiologists must
comply with Health Insurance Portability
and Accountability Act (1996). Virtual
Private Networks and encryption are
recommended
Nil
Lee (2018)
22
SLP intern provided Rx to patient’s
home using enhanced VC (pre-
sencelearning.com). Parents acted
as facilitators (opening sessions,
assisting child during sessions,
troubleshooting)
A: Child’s home in West Texas,
US
B: Telepractice Research Lab at
university in Texas
Caregivers received intensive training
(one IP and one online) in how to
use the software, how to assist
the child during Ix and basic
troubleshooting and online prac-
tice session to resolve any tech-
nical difficulties. When caregivers
felt confident, Ix began
Nil Nil
Markie-Dadds and
Sanders (2006)
17
Parents completed program using
written materials, parents called
psychologist weekly on a toll-free
phone number to discuss pro-
gram materials
A: Family home, rural and remote
communities in southern
Western Australia
B: Department of Families and
Children’s Services
Nil Nil Nil
Monica et al.
(2017)
36
Store and forward video-otoscopy
(email). Real-time tele-screening
(Teamviewer version 10). Teacher
(facilitator) connected hardware,
A: Elementary school
B: Sri Ramachandra University
Hospital, Chennai, India,
400 km away
Each day, best Internet connection
was chosen. Facilitator was
trained for two days and training
booklet provided
Multiple Internet options should be used for
sustained connectivity, e.g. mobile phone
and dongle. Facilitator known to children
contributed to success
Nil
(continued)
Campbell et al. 11
Table 4. Continued
Study Service model A: Locations B: Patient provider Implementation actions Implementation recommendations
Implementation
model
placed headphones, inserted
probe and sanitised equipment
Ramkumar
et al. (2018)
37
Children underwent ABR testing in a
mobile tele-van using satellite
connectivity or at a local centre
using broadband Internet
A: Mobile van or health NGO
B: Tertiary hospital in
Chennai, India
Village health workers were trained
for five days and selected for
screening after their competence
was assessed. Skills were regularly
reviewed. This is suggested as
resulting in high specificity in
screening outcomes
Nil Nil
Ramkumar et al.
(2018)
38
1. Village health workers screened
children in their homes using a
two-step DPOAE screening pro-
tocol
2. Children referred to second
screening underwent tele-diag-
nostic ABR testing in a mobile
tele-van using satellite connectivity
or at a local centre using broad-
band Internet at the rural location
A: 1) Tele-van (satellite) in 51
villages and hamlets in Tamil
Nadu region, India
2) NGO centre (broadband) in
villages
B: Sri Ramachandra University,
Chennai (70 km from villages)
Specialised training for village
health workers
Nil Nil
Reese et al.
(2015)
28
Psychologist provided parenting pro-
gram via VC to spoke hospitals
and schools
A: One hospital, two public
schools in rural Kentucky, US
B: University
Nil Prepare parents to anticipate audio or video
quality issues
Nil
Scheideman-Miller
et al. (2002)
29
Ax conducted prior. Pre-pilot: pro-
vider SLP conducted Rx via VC
assisted by school SLP. Provider
SLP also provided consultation
services to school SLP
Pilot: provider SLP conducted Rx to
school assisted by Rx aide
Pre-pilot: A: Choctaw Memorial
Hospital conference room in
Hugo, Oklahoma US. B:
INTEGRIS Jim Thorpe
Rehabilitation Centre,
Oklahoma City, 178 miles
from Hugo
Pilot: A: Hugo Elementary School
B: INTEGRIS Southwest Medical
Center in Oklahoma City
Pre-pilot. Education by school
administrators of school board
and community. Open house
demonstration. Prior familiarity
with video technology in the
classroom. Meetings between
metro/rural partners and between
principal/partners/project techni-
cal director/ school communica-
tions coordinator. Use of teacher’s
aide. Presenting feedback to part-
ners. Technical problem isolation
requiring problem resolution
between partners resulting in
installing a dedicated commer-
cial line
Noisy area (adjoining cafeteria) unsuitable.
Students less than seven found to were
years old unsuitable (less attentive).
Consider using analogue phone lines
where a dedicated line cannot be
installed. Develop manual and short
course on effective use of TH for Rx
Nil
Sicotte et al.
(2003)
30
Ax conducted prior. SLP provided
stuttering Rx to parent and child
at via VC. Parent assisted SLP and
helped keep child focused on
the activity
A: Primary care centre, Matane,
Quebec, Canada
B: Paediatric tertiary care
centre, Montreal
Nil Nil Nil
(continued)
12 Journal of Telemedicine and Telecare 0(0)
Table 4. Continued
Study Service model A: Locations B: Patient provider Implementation actions Implementation recommendations
Implementation
model
Stewart et al.
(2017)
31
Ax conducted prior. Therapist deliv-
ered direct VC Rx to:
1) nine students at school
2) four students at home
3) two students at school then home
A: Schools and child’s homes,
South-eastern US
B: Academic medical centre, 40–
110 miles away
Pre-treatment visits to survey physi-
cal premises and build relation-
ships. Clinicians had contact
information for school staff.
Emergency plans discussed. Pre-
downloading necessary software
directly on to equipment. Easy to
understand step-by-step instruc-
tions on how to log in and con-
nect. Allowing time for child,
parent and staff to practice using
the equipment and connect prior
to beginning treatment. School
visit to set up the equipment.
Reminder calls and text messages.
Directly addressing caregiver
concerns and barriers at initial
appointment and throughout
treatment. Addressing ethno-cul-
tural beliefs and attitudes related
to mental health treatment.
Linguistically competent clinicians
Test equipment. Use detailed and easy-to-
understand instructions, allow child/care-
giver/staff to practice equipment use
User-centred
approach
40
Sutherland et al.
(2017)
39
Remote assessor conducted some
subtests via VC. IP SLP acted as
facilitator e.g. turned on comput-
er, logged in, then observed Ax
A: Three rural New South Wales
schools, one suburban Sydney
school, Australia
B: Westmead hospital.
Sydney, Australia
Training in the platform for
SLPs (<30 min)
Important for children involved in TH Ax to
be supported to ensure they attend and
interact appropriately
Nil
Swift et al.
(2009)
18
Non-specialist clinician made phone
contact to support parents’ prog-
ress through the self-
help materials
A: Parent’s home, south-eastern
region of South Australia.
B: Paediatric mental health clinic
Nil Nil. Nil
Wilson et al.
(2004)
32
Ax completed prior. SLP provides
stuttering Rx by phone to parent
at home, with a hotline available
between appointments. Parents
mail audio modelling of imple-
menting Ix with child to clinician
for feedback at next consultation
A: Family home, various locations
in Australia
B: University setting
Nil Delivery via VC should be investigated Nil
Ax: Assessment; Dx: diagnosed; IP: in-person; Ix: intervention; Rx: therapy; SLP: speech-language pathologist; TH: telehealth; VC: videoconference.
Campbell et al. 13
from a university setting.
20–23,28,31,32,34–36,38
Clinicians
provided services from a hospital or a combination
of hospital and another venue,
26,29,30,37,39
undisclosed
locations,
19,24,33
government services,
17,27
a non-
governmental organisation
25
and a mental
health clinic.
18
Quality
The number of criteria met on CASP checklists ranged
from 1/12 (8%) to 10/10 (100%) (the full results are
presented in supplementary material).
Some questions were not relevant to the study and
were not counted in the total. Only one study met all
relevant checklist criteria,
35
indicating a poor quality of
evidence overall.
Findings
All studies reported that TH delivery was feasible to
deliver the intervention. The audiology study that met
100% of CASP criterion found that otoscopy and
immittance (middle-ear functioning) results were iden-
tical in TH and in-person conditions. It described high
sensitivity and specificity for otoscopy and immittance,
but low specificity for TH pure-tone screening.
35
The
two studies at the highest level of evidence (NHMRC
level II) found that self-directed parent programs with
telephone support were effective in reducing child
behaviour problems.
17,18
Investigation of TH implementation
No studies asked research questions about implemen-
tation itself. Only one study referred to a theoretical
model regarding TH implementation. Stewart et al.
31
briefly referred to a user-centred approach
40
for imple-
menting new technology, while referring to implemen-
tation facilitators such as testing equipment, providing
instructions and having the child/caregiver/staff prac-
tice using equipment beforehand.
More than half of the studies (n¼12) described
actions taken by authors to facilitate TH implementa-
tion or recommended actions to facilitate implementa-
tion. No studies measured the impact of these actions.
The most common action taken was to provide
information or training about equipment and proce-
dures to facilitators,
19–22,31,36,38,41
children,
33
clini-
cians
39
or parents.
26
Training recommendations
included practicing with the technology,
31
preparing
parents to anticipate audio or video quality issues,
28
developing a manual and short course for providers
about how to most effectively use TH for therapy
29
and detailed easy-to-understand instructions.
31
Two
studies described providing education and feedback
about the program to a broader range of stakeholders,
such as a school board and community,
29
parents, care-
givers and schools.
25
Recommendations pertaining to
the equipment used in TH consultations included: pre-
downloading software for clients; testing equipment
31
;
improving and monitoring connectivity
25
; using quality
equipment
27
; and taking time to pre-arrange direct net-
work access in schools.
35
Only two studies made recommendations unique to
rural areas. They recommended analogue phone lines if
dedicated Internet lines could not be installed
29
and
daily testing of available connection methods to select
the best connection.
36
Four studies highlighted child-specific implementa-
tion facilitators. These were using assistants,
27,36
safe
clinical environments with child-sized furniture,
27
selecting children who can focus and attend to ses-
sions,
27,29
providing shorter sessions for younger chil-
dren
27
and allowing children to practice with
equipment.
31
Discussion
This review aimed to identify the scope of literature
investigating TH delivery of allied health services to
rural children. Using NHMRC levels of evidence and
CASP checklists, we found low-level, low-quality evi-
dence, suggesting that TH is feasible in a limited range
of behavioural, communication and audiological
interventions.
Many of the interventions described therapy rather
than assessment, were individual rather than universal
and used videoconferencing to connect university set-
tings to educational settings. These findings are of lim-
ited use for allied health practitioners who conduct
both assessment and therapy, use universal or group
approaches, or work in community, public or pri-
vate settings.
The absence of dietetics and social work from this
literature is particularly surprising given their use of
consultative approaches. Coaching and consultative
models of physiotherapy and occupational therapy,
such as occupational performance coaching,
42
were
also absent. This suggests that these disciplines may
be underserving children in rural areas due to this
gap in research.
In summary, this review reveals large gaps in TH
literature for rural children who require allied health-
care. Available literature omits multiple disciplines and
neglects large-scale, community-based approaches to
focus on individual therapy and educational settings.
This study is the first to review implementation fac-
tors in rural paediatric allied health. The included stud-
ies identified information, training and equipment
considerations, but failed to go beyond these to discuss
how clinician acceptance
43
and features of
14 Journal of Telemedicine and Telecare 0(0)
organisations
44
influence TH success and failure. It
appears that researchers are failing to employ available
robust theoretical models to understand TH implemen-
tation (e.g. Liu,
45
Wade et al.
46
) despite concerns about
the gap between research and practice in TH.
47
This review is also the first to identify implementa-
tion factors specifically for rural contexts. Previous
reviews in paediatric allied health TH did not distin-
guish between rural and non-rural participants.
48,49
This review identified the need to arrange or exploit
alternative Internet connections in rural settings.
29,36
Dedicated Internet lines may need to be installed, or
facilitators may need to switch back and forth between
available Internet connections, depending on the con-
nection. This introduces additional time, cost and prac-
tice requirements for rural clinicians that must be
accounted for in TH research.
This review is also unique in summarising child-
specific implementation facilitators identified to
date – namely, the use of assistants or helpers,
27,36
child-friendly environments,
27
selecting children care-
fully,
27,29
shortening sessions with young children
27
and allowing children to practice with equipment.
31
The impact of these facilitators is yet to be rigorously
investigated.
Limitations and future directions
Results from Asia-Pacific outside India, Africa and
South America were absent. Future research should
include the translation of non-English articles to address
the limited geographical scope of these findings.
TH research in paediatric rural occupational therapy,
physiotherapy, dietetics and social work is urgently
needed to encourage the development of services for
rural children. Research with Australian Indigenous
children should be prioritised as they are more likely
to be developmentally vulnerable than non-
Indigenous children.
3
Researchers should collaborate with community,
public and private organisations to investigate TH
services via available infrastructure in rural areas
rather than relying on university and hospital infra-
structure unavailable to consumers. Practice-based
research and implementation science approaches are
useful approaches in such contexts.
50,51
Pragmatic
trials that include both assessment and therapy
should be given priority. As rural areas require fewer
clinicians to work across wider areas than metropolitan
peers, clinical and cost-efficiency measures should be
employed. Universal and non-traditional group inter-
vention should be examined given their potential to
increase reach and lower costs.
The limited focus on training and equipment imple-
mentation factors in the included studies contrasts with
general telemedicine research, which identifies an array
of technical, usability, protocol, regulation/policy and
organisational barriers.
43,44
A wide range of implemen-
tation factors should be identified and analysed, includ-
ing clinician and organisational acceptance and how
rural clinicians and organisations successfully respond
to poor Internet connections, low community aware-
ness and the demands of child-friendly practice.
None of the studies discussed the sustainability of
TH services or which implementation factors contrib-
uted to sustainability. Most studies, with two excep-
tions,
23,29
were conducted over periods of less than
six months. Sustainability is a key aspect of TH suc-
cess
52
and should be investigated over longer periods.
Conclusion
This review identifies the need for clinically useful TH
research with an implementation focus across paediat-
ric allied health disciplines for rural children. Research
should investigate TH delivery of usual care (both
assessment and therapy) as well as universal and
group intervention. Clinical effectiveness data must
be supplemented with the identification of successful
and unsuccessful implementation strategies, and
cost- and clinical-efficiency analyses. Community,
public and private settings should be prioritised. If
rural children are to achieve the same developmental
outcomes as city-dwelling peers, further research on the
implementation of new TH services is required.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship and/or publication of this
article: BUSHkids funded the first author’s PhD stipend.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
ORCID iD
Jessica Campbell https://orcid.org/0000-0003-1759-4012
Trevor Russell https://orcid.org/0000-0002-9732-6167
Supplementary Material
Supplementary material is available for this article online.
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